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PERMITTEE NAME/ADDRESS (Include Facility Name/Location if Different)
<br />NAME
<br />ADDRESS G--`r,; s i _ ?.} t + (ir
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<br />FACILITY
<br />LOCATION
<br />NATIONAL POLLUTANT DISCHARGE ELIMINATION SYSTEM (NPDES)
<br />DISCHARGE MONITORING REPORT (DMR)
<br />602
<br />PERMIT NUMBER DISCHARGE NUMBER
<br />MONITORING PERIOD
<br />YEAR MO DAY YEAR MO DAY
<br />FROM TO ?.i ... r
<br />Form Approved.
<br />OMB No. 2040-0004
<br />1 ??'l? R?'t { t: t I
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<br />NOTE. Read Instructions before completing this form.
<br />PARAMETER QUANTITY OR LOADING QUALITY OR CONCENTRATION ND, FREQUENCY SAMPLE
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<br />TYPE
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<br />NAME/TITLE PRINCIPAL EXECUTIVE OFFICER 1 certify under penalty of law that this document and all attachments were
<br />d
<br />d
<br />i
<br />i TELEPHONE DATE
<br /> prepare
<br />un
<br />er my d
<br />rect
<br />on or supervision in accordance with a system designed -
<br />a
<br />5 ? [o assure that qualified personnel properly gather and evaluate the information
<br />submitted. Rased on m} inquiry of the person or persons who manage the system,
<br />
<br />.I'
<br /> or those persons directly responsible for gathering the information, the information rte'
<br /> submitted is, to the best of my knowledge and belief, true, accurate, and complete.
<br />
<br />1 am aware that there are si
<br />nificant
<br />enalties for submittin
<br />false information IGNATURE OF PRINCIPAL EXECUTIVE
<br />
<br />TYPED OR PRINTED g
<br />p
<br />g
<br />,
<br />including the possibility of fine and imprisonment for knowing violations.
<br />OFFICER OR AUTHORIZED AGENT
<br />A
<br />CODE
<br />NUMBER
<br />R
<br />MO
<br />DAY
<br />UUMMtrv 10 ANU CArLANA I IUIV yr Pull T V FULA I IUND (nererence an arracnmenrs nere)
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<br />EPA Form 3320-1 (Rev. 3/99) Previous editions may be used. t, 1TfdS:A1? 3%4-r sj'fbrm. PAGE
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